Any part of the gastrointestinal tract may become perforated, releasing gastric or intestinal contents into the peritoneal space. Causes vary. Symptoms develop suddenly, with severe pain followed shortly by signs of shock. Diagnosis is usually made by the presence of free air in the abdomen on imaging studies. Treatment is with fluid resuscitation, antibiotics, and surgery. Mortality is high, varying with the underlying disorder and the patient’s general health.
Both blunt and penetrating trauma can result in perforation of any part of the gastrointestinal tract (see table Some Causes of Gastrointestinal Tract Perforation ).
Swallowed foreign bodies, even sharp ones, rarely cause perforation unless they become impacted, causing ischemia and necrosis from local pressure (see Foreign Bodies in the Gastrointestinal Tract ).
Foreign bodies inserted via the anus may perforate the rectum or sigmoid colon (see Rectal Foreign Bodies ).
Some Causes of Gastrointestinal Tract PerforationSome Causes of Gastrointestinal Tract Perforation
Typically perforation with an esophagoscope, balloon dilator, or bougie
Ingestion of corrosive material
Stomach or duodenum
Can occur in patients with no previous history of ulcer symptoms
Sometimes no free air is visible on radiograph
Ingestion of corrosive material
Free air rarely visible on radiographs
Typically perforates at cecum
High risk: Colon ≥ 13 cm diameter, patients receiving prednisone or other immunosuppressants (symptoms and signs may be minimal in this group)
Iatrogenic injury during cholecystectomy or liver biopsy
Usually the biliary tree or duodenum is injured
Usually walled off by omentum
Esophageal, gastric, or duodenal perforation tends to manifest suddenly and catastrophically, with abrupt onset of acute abdomen with severe generalized abdominal pain, tenderness, and peritoneal signs . Pain may radiate to the shoulder.
Perforation at other gastrointestinal sites often occurs in the setting of other painful, inflammatory conditions. Because such perforations are often small initially and frequently walled off by the omentum, pain often develops gradually and may be localized. Tenderness also is more focal. Such findings can make it difficult to distinguish perforation from worsening of the underlying disorder or lack of response to treatment.
In all types of perforation, nausea, vomiting, and anorexia are common. Bowel sounds are quiet to absent.
An abdominal series (supine and upright abdominal radiographs and chest radiographs) may be diagnostic, showing free air under the diaphragm in 50 to 75% of cases ( 1 , 2 ). As time passes, this sign becomes more common. A lateral chest radiograph is more sensitive for free air than a posteroanterior radiograph.